Question

Situation/Transition

Stimuli are reduced and therapeutic communication is used, the patient allows the nurse to administer IV lorazepam. After the lorazepam is administered, the patient becomes increasingly anxious and agitated, and symptoms of alcohol withdrawal become more severe.

Physiologic State 2

T = 99.6 F (37.6 C)

BP = 160/98
Pulse = 125
RR = 26

O2 Sat = 97% (room air)

Patient screams, "Do something to make this feeling go away, or so help me, I am getting out of here and getting a drink! I want a cigarette NOW! (Shouts obscenities.)"

1. What shall the nurse evaluate after interventions have been implemented?

2. Identify 2 nursing diagnoses and 2 patient’s goals for each nursing diagnosis?

a) Nursing Diagnosis / Goals:

b) Nursing Diagnosis / Goals:

Answer 1

1 . Lorazepam is a benzodiazepine class of drug that is intermediate acting lasts for 10 to 20 hours. It increases the effect of GABA which inturn reduces the activity of neurons providing calming effect.

Therefore, the nurse has to evaluate for the effectiveness of lorazepam . As the minutes pass by the restlessness, anxiety, irritability from alcohol withdrawal decreases .

The nurse evaluates for behavioral change , vital signs, mental status by mental status examination of the patient.

2 . Nursing diagnosis :

a . Anxiety/ Restlessness related to sudden withdrawal of alcohol intake.

Goals :

• Patient verbalises decreased restlessness and anxiety.
• Patient is able to keep calm and maintain dignity.

b. ) Risk for injury related to aggressiveness secondary to withdrawal symptoms.

Goals :

• Patient is free from injury by providing safe environment.
• Patient calms down through administration of benzodiazepines.

Thank you.